Provider Demographics
NPI:1871576090
Name:STUBBLEFIELD, PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:STUBBLEFIELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 E CONCORD ST
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2335
Mailing Address - Country:US
Mailing Address - Phone:617-414-5174
Mailing Address - Fax:617-414-7300
Practice Address - Street 1:720 HARRISON AVE
Practice Address - Street 2:11TH FLOOR, SUITE 1105
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2371
Practice Address - Country:US
Practice Address - Phone:617-638-8131
Practice Address - Fax:617-638-8040
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA35488207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2006642Medicaid
MAA37968Medicare UPIN
MA2006642Medicaid